1. A diabetic patient with a new foot ulcer expresses distrust in the wound care specialist's plan, insisting on home remedies. The nurse notes elevated HbA1c and +2 pedal edema. Which collaborative strategy is most appropriate?
Answer: C
This integrates clinical cues (ulcer, HbA1c, edema) with patient autonomy via interprofessional engagement. Option A neglects trust-building and holistic care. Option B delays wound management and isolates cultural factors from medical needs. Option D overrides patient concerns, risking nonadherence. AMSN guidelines advocate collaborative problem-solving for complex cases involving comorbidities and patient values, ensuring care plans are medically sound and culturally respectful.
2. A 45-year-old with fibromyalgia reports persistent pain despite acetaminophen use. They have a history of gastric ulcers and report daytime sedation concerns. Which adjuvant best addresses these considerations?
Answer: C
Milnacipran is FDA-approved for fibromyalgia without GI ulcer risks or sedation. Amitriptyline (A) and cyclobenzaprine (B) cause sedation and anticholinergic effects that may worsen ulcers. Gabapentin (D) causes sedation but isn't first-line for fibromyalgia. SNRIs like milnacipran improve pain/fatigue with lower GI risk than TCAs or muscle relaxants, aligning with fibromyalgia guidelines.
3. A nurse reviews data for a diabetic patient with a non-healing foot ulcer: mid-upper arm circumference (MUAC) 80% of standard, prealbumin 10 mg/dL, and oral intake at 50% of meals for 2 weeks. Which combination best supports a malnutrition diagnosis?
Answer: A
Reduced muscle mass (MUAC <85%) plus inadequate intake >1 week meets ASPEN criteria for malnutrition. Prealbumin (B,D) is unreliable with inflammation from the ulcer. The ulcer (C) complicates nutrition but isn't a direct sign. MUAC objectively measures protein stores, while documented intake deficit provides etiology, creating a clinically validated pairing.
4. A 62-year-old patient with type 2 diabetes and limited health literacy is discharged after a foot ulcer infection. They live alone in a rural area 30 miles from the clinic and report inconsistent access to transportation. Which coordination strategy prioritizes social determinants of health for follow-up care?
Answer: B
This addresses both cues: geographic isolation (telehealth overcomes distance) and transportation barriers (community partnerships). Option A ignores transportation access, risking missed appointments. Option C uses home health but doesn't resolve transportation for future self-management. Option D relies on sporadic family help, which is unsustainable for daily care. CMSRN standards emphasize leveraging technology and community resources to mitigate access barriers, promoting continuity of care where social determinants limit traditional follow-up.
5. A patient with COPD on 2L/min oxygen has postoperative ileus. They use warfarin (INR 2.8). Which acupressure method is appropriate?
Answer: C
LU7 supports respiratory function, critical in COPD, and gentle pressure avoids bleeding risk with therapeutic INR. CV12 (A) and BL25 (B) could exacerbate ileus via vagal stimulation and are contraindicated with anticoagulation. KD3 (D) lacks evidence for ileus. LU7 aligns with ATS/ERS guidelines prioritizing oxygenation in COPD while minimizing hemorrhage risk, making it safer than abdominal techniques.
6. In a contaminated bowel resection case, the final sponge count is incorrect after fascial closure. The patient is immunosuppressed from chemotherapy. The surgeon is irrigating the wound before skin closure. What is the priority action?
Answer: B
Fascial reopening allows direct search, preventing retained objects in immunosuppressed patients where infections are catastrophic. Irrigation (A) doesn't resolve count failure. Postop imaging (C) delays resolution. Re-counting (D) ignores cavity inaccessibility. Cues are post-fascial closure and immunosuppression, necessitating re-entry despite contamination risks.
7. During interdisciplinary rounds, a diabetic patient with a gangrenous foot ulcer expresses reluctance toward amputation despite sepsis signs. The surgeon insists on surgery, while the palliative nurse advocates for comfort care. How should the medical-surgical nurse facilitate resolution?
Answer: C
An ethics consult addresses care conflicts involving patient values (reluctance) and medical urgency (sepsis) per AMSN standards. Option C fosters collaborative decision-making without coercion. Option A violates autonomy by bypassing the patient. Option B disregards the palliative perspective and patient wishes. Option D delays time-sensitive care; capacity assessment is unwarranted without cognitive concern cues. The gangrene/sepsis context requires balancing medical necessity with ethical obligations.
8. A nurse notes a newly admitted patient with cirrhosis has a potassium level of 5.9 mEq/L but was documented as "normal" by the covering provider. The primary provider returns in 30 minutes. Which action demonstrates assertive communication?
Answer: C
Assertive communication addresses urgent risks directly. Hyperkalemia in cirrhosis risks arrhythmias; Option C provides critical data and seeks prompt intervention per ACLS guidelines. Option A delays action for a life-threatening value. Option B ineffectively targets the covering provider who isn't managing care. Option D is unsafe; hyperkalemia requires treatment before reconfirmation. The cirrhosis comorbidity increases vulnerability to electrolyte imbalances.
9. To control labor costs, a nurse evaluates tasks for delegation. A patient with cirrhosis has ascites (needing paracentesis prep), hypertension monitoring, and assistance to ambulate. Which delegation decision is appropriate?
Answer: A
Paracentesis education/consent requires RN assessment of comprehension/risks. UAPs can perform ambulation/vitals. Option B: LPNs cannot independently handle invasive procedure prep. Option C misprioritizes RN skills for ambulation over complex education. Option D: Hypertension education may be LPN-appropriate, but paracentesis demands RN involvement. Aligning RN with high-risk tasks maximizes resources while containing costs through UAP support.
10. A diabetic patient with chronic kidney disease (eGFR 28 mL/min) develops new foot ulcers. Which educational need assessment strategy prioritizes safety while addressing comorbidity interactions?
Answer: B
Foot ulcer development in renal-impaired diabetics (eGFR cue) elevates infection/amputation risk, making direct skills assessment (B) urgent. Option A ignores new ulcers. Option C focuses on long-term control, not acute complications. Option D addresses fluid management but not wound risks. CMSRN protocols prioritize hands-on assessment for high-risk skills when comorbidities intersect with new complications.
11. An ESRD patient receiving hemodialysis misses two sessions and presents with K+ 6.8 mEq/L, peaked T-waves, and muscle weakness. After initiating cardiac monitoring, which action aligns with clinical judgment measurement?
Answer: C
Peaked T-waves indicate hyperkalemic cardiac toxicity requiring immediate membrane stabilization with calcium gluconate per KDIGO guidelines before addressing potassium removal. Dialysis (B) is definitive but takes time. Sodium polystyrene (A) acts slowly and risks bowel necrosis. Dietary restriction (D) is preventive, not emergent. Membrane stabilization protects against cardiac arrest while arranging dialysis.
12. On postoperative day 10, a jejunoileal bypass patient has bilious NG output >1.5L/day. Abdominal CT shows no mechanical obstruction, but ileus persists. BMI is 16, transferrin 150 mg/dL. What nutrition support is indicated?
Answer: B
Prolonged ileus (>7 days) with high-output fistula, severe malnutrition (BMI 16), and depleted visceral proteins necessitates TPN. PPN (Option C) is inadequate for comprehensive nutrition in chronic high-loss states. Option D risks aspiration and worsens output. Option A neglects nutritional requirements. Trace element monitoring is critical in high-output GI losses per ASPEN standards. TPN provides complete nutrition while bowel rest is achieved.
13. A patient with cirrhosis and hepatic encephalopathy exhibits asterixis and confusion. Family reports they took ibuprofen for back pain yesterday. Which assessment is most urgent?
Answer: C
NSAID use in cirrhosis risks GI bleeding, which can precipitate encephalopathy by increasing ammonia. Option B monitors encephalopathy but won't identify active bleeding. Option A evaluates fluid status but doesn't address the acute change. Option D assesses consciousness but not etiology. AASLD guidelines prioritize GI evaluation for acute neurological decline in cirrhotic patients.
14. A 68-year-old patient with a history of stroke-induced dysphagia and GERD has a newly placed nasogastric tube for enteral feeding. On day 2, the nurse notes gastric pH is 6.0 via pH strip testing before intermittent feeding. The patient is alert but coughing occasionally. Which action aligns with current enteral nutrition guidelines?
Answer: B
X-ray remains the gold standard for initial tube placement confirmation per ASPEN guidelines, especially with new tubes or ambiguous pH (>5). Option A ignores unreliable pH results in patients on acid-reducing medications (GERD history) and cough suggesting possible aspiration. Option C risks bronchial placement advancement. Option D uses invalidated auscultation method. Coughing and pH 6.0 create high-risk cues requiring definitive imaging before feeding.
15. A patient with active ulcerative colitis and recent open hysterectomy develops unilateral leg swelling. Warfarin is contraindicated due to hematochezia. Which prophylactic regimen complies with ASH guidelines?
Answer: A
Mechanical prophylaxis is recommended when anticoagulants are contraindicated due to bleeding risks (GI bleed, recent surgery). ASH guidelines specify this for high-bleed-risk patients. Options B and C are anticoagulants that could exacerbate bleeding. Option D is ineffective for VTE prophylaxis post-major surgery. Compression devices reduce DVT risk without bleeding complications, aligning with the patient's contraindications.
